Provider Demographics
NPI:1023337813
Name:JARRELL, KANDI LAMAY ELRAY (LMP)
Entity type:Individual
Prefix:MRS
First Name:KANDI
Middle Name:LAMAY ELRAY
Last Name:JARRELL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1122 NE KELLY AVE APT K136
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3977
Mailing Address - Country:US
Mailing Address - Phone:503-766-2332
Mailing Address - Fax:
Practice Address - Street 1:15811 AMBAUM BLVD SW
Practice Address - Street 2:SUITE 110
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-3066
Practice Address - Country:US
Practice Address - Phone:206-242-8211
Practice Address - Fax:206-242-0162
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60132570225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist